Provider Demographics
NPI:1144325879
Name:HARDESTY, SAMANTHA MAE (LMP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MAE
Last Name:HARDESTY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BROADWAY STE C
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663
Mailing Address - Country:US
Mailing Address - Phone:360-326-5288
Mailing Address - Fax:
Practice Address - Street 1:2200 BROADWAY STE C
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-326-5288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0193869OtherLABOR AND INDUSTRY